ICP New Member Application


    Fill out each tab below, clicking [Next >>] when completed, then click [Submit Application].

Member Overview / Summary
Contact Info Email Address needs to be updated:
Contact Info Mailing Address needs to be updated:
Contact Name:
Membership ID:
Contact Email Address:
Affiliation:
Membership Classification:
Current Amount Due: $
Make a Donation:
Contact information made available on ICP website:
Member Classification
Member Classification applying for *



Login Information
How did you hear about the ICP?
Username: *
Password: *
Confirm Password: *
Check the following box to make you information public on the ICP website (Find a Member).*
Contact Information
Title:
First Name/Given Name/Forename: *
Last/Surname/Family Name: *
Country: *
Address 1: *
Address 2:
Address 3:
Address 4:
City: *
State/Province/Region: *
Zip/Postal Code:
Telephone Number (include country code):
Email Address: *
Organization Information
Organization Name:
Acronym for Organization:
Organization's General/Public Email Address:
Organization's Website Address:
Does organization provide conferences for members?
Location of your next general meeting:
Website URL of your next general meeting:
Date of your next general meeting:
Organization is a: (Select all that apply)
National Organization:
International Organization:
Local/Provincial/State Organization:
Organization's membership include: (Select all that apply)
General Dentists:
Specialist Prosthodontists:
Other Specialist Groups:
Dental Hygienists:
Technologists:
Scientists:
Does organization provide certification or credentialing at any level?      
Is organization certified or registered as a continuing education provider?      
IJP Information. Complete this address for IJP delivery.
Mail Address
Same as Contact Information?
Country:
Address 1:
Address 2:
Address 3:
Address 4:
City:
State/Province/Region:
Zip/Postal Code:
Journal Request History
to change your mailing address on an existing order below, click 'Edit Address' which will load the address above. Then click 'Save Updated IJP Address'
Affiliation Information
University / Institution / Affiliation / Private Practice:
Department:
Position / Title:
Personal / Private Practice Website URL:
Education Information
Licensed?
Certified?
Professor?
Undergraduate School Attended:
Undergraduate Degree Completed on:
Graduate School Attended:
Graduate Degree Completed on:
Are you currently enrolled in a full time recognized Prosthodontic training program?
Other Information
Date of Birth
Other Organizational Memberships
Membership Reference List one (1) ICP Constituent Member for reference
First Name
Last Name
Email Address:
Member Photos

(Note: Photo file extension cannot contain UPPER CASE characters (e.g. on your computer, richt click & rename yourfile.JPG to yourfile.jpg)
Select photo to upload:  

  Is Main PhotoPhoto NameUploaded
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Member Registration Payments
NOTE: IJP subscription will begin 4-6 weeks after payment. Mailing of back issues no longer provided. Refer to internet on-line subscription to view back issues.
                     



Membership Amount Owed *
(includes previous years and any late fees or processing fees)
$
 
1.
2.
2. Split to both funds

Enter Donation amount:       $

Total amount of transaction: $

Credit Card Information
Card Number *
Card ID/CCV * (3 or 4 digit number on back of card)
Card Expires *
Name on Card * First: Last:
 



(Administrative Use Only!)
Username:
Password:
Payment History
Amount PaidDate
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Donation History
Donation AmountTypeDate
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Make a Donation
The ICP appreciates your generosity and support for the initiatives listed below.
Click on each Program for additional detail.
Your ICP Donations can be applied to a specific program or shared. Choose your favorite:


Credit Card Information
Donation Amount $
Card Number
Card ID/CCV (3 or 4 digit number on back of card)
Card Expires
Name on Card First: Last:
 




(Administrative Use Only!)
Username:
Password:
Member Classification Change
  • If you are a Student and request change to Affiliate, press “Request Change” button for Affiliate
  • If you are a Student or Affiliate and request change to Constituent, 1st: fill out comment box below and provide information, then 2nd: press "Request Change" button to Constituent Member:
          Are you a full time senior teacher in prosthetic dentistry? Are you licensed or certified as a prosthodontist?
          Undergraduate school attended and degree? Graduate school attended, degree and date you received your degree?

  • If you are a Constituent member and request Life Member, fill out comment box regarding criteria posted under Life Member definition, then press "Request Change" button for Life Member.
The Membership Committee will review your request for consideration and respond shortly.

Comments:
 Classification
Affiliate (Annual Dues: $250, Processing Fee: $50 , Includes IJP: Yes)
Affiliates are Dentists or scientists* who do not qualify as Constituent members but have demonstrated contributions to prosthodontics. *Scientist is interpreted by the ICP as a clinical or basic scientist with graduate degree qualifications who has demonstrated a contribution to the specialty of prosthodontics.
Constituent (Annual Dues: $250, Processing Fee: $50 , Includes IJP: Yes)
Constituent Members of the College shall be those individuals who have completed an accredited formal prosthodontic training program or are licensed as a prosthodontist by their governing body/licensing authority for dentistry. In countries with no specialty course in prosthodontics, full-time senior teachers in prosthetic dentistry may qualify for constituent membership. Documents required to confirm certification as a prosthodontist or teacher.
Life Member (Annual Dues: $0 , Includes IJP: No)
Life Members of the College shall be those Constituent Members who apply for Life Membership, or are proposed by the Board of Councilors, and who have held memberships in the College for at least ten consecutive years immediately prior to applying or being proposed and who have attained the age of 65, or who because of illness, are retiring from active participation in prosthodontics and dentistry in general. Life Members may vote in College business or elections but may not hold elective office.

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